1 Patient profile: Name, Age, Sex, Address, DOA, DOE

2 Presenting complaints: Chronological order

3 History of Presenting complaints:

Mr. / Miss came with c/o …..For ……

H/O EAR DISCHARGE: DOC4OBA2

1 Duration 2 Onset – Insidious/ gradually progressive/ 3 Continuous/ Intermittent (Duration, frequency,

how long it last) 4 Color- Yellowish/ White/Colorless 5 Character- Mucoid /Mucoprullent/ Purulent
6 Consistency-Thick /Thin 7 Odor-Foul smelling/Not 8 Blood stain / Not 9 Amount- Scanty/ Moderate/
Profuse 10 Aggravating /Relieving factor

H/O Hearing loss

1 Duration 2 Onset- Insidious/ gradually progressive/ sudden 3 Progression-static/ gradually progressive

4 Fluctuations 5 Hampering social lice/ Not 6 continuous/intermittent

H/O

1 Earache 2 Ringing sensation of ear (Tinnitus) 3 Dizziness ( Vertigo) 4 Trauma to ear 5 Exposure to loud
noise 6 Ototoxic drug in past ….7 Pre/ Post/infra auricular swelling 8 Facial asymmetric 9 Deep seated
headache 10 High grade fever 11 Projectile Vomit 12 Blurring of vision 13 Abnormal body movement 14
altered sensorium 15

H/O Throat / Nasal symptom

Rx History if present

4 Past history: H/O PTB , DM , HTN , ASTHMA, Surgery in the past, previous RT

5 Family history: H/O PTB , DM , HTN , ASTHMA, H/O Ear discharge / Hearing loss in family

6 Personal history: H/O Ear pricking habit /Not , H/O swimming /Not , Nasal blowing/Not

Smoking /Not, Consume alcohol/Not, Bladder, Bowel, Menstruation ,Sleep

7 Socioeconomic condition :

8 Allergic to aspirin or other drug

Menstrual history :- in female

Dietary history :- eg in thyroid

IN PEDIATRIC U MUST MENTION

1 Perinatal History: Maternal immunization (TORCH), Maternal infection, Drug intake /Not, Exposure
to radiation /Not

2 Delivery: Home /Hospital/Nursing home, Full term/Pre term, vaginal/ CS/ Forceps

3Developemental: 1st social smile (6wkk), Roll over (6mts), Sits with support (3-4 mts), Sits without
support (6mts), stand with support (1 yr), Stand without support ie; walk (1-1/2 yr)

4 Immunization – according to EPI

BCG – At birth 1 dose (0.05ml) Intradermal (upper & outer arm)

Polio – At birth, 6, 10, 14 wkk (3 dose) 2-3 drop P/O

DPT- 6, 10, 14 wkk (3 dose) 0.5 ml (IM upper & outer part of mid thigh)

Measles – 9 mts (1 dose) 0.5 ml (subcutaneous)

TT – At first contact , 4 wkk, 6 mts , 1 yr ,1yr ,( 5 dose ) 0.5 ml (IM – upper & outer arm)

5 Physical abnormality: 6 School performance:

7 Appetite:
8 Family sibs: 9 Pet at home:

ON EXAMINATION:

GENERAL EXAMINATION:

APPEARANCE: Fair / ill looking Body built: Average / Emaciated, Nutrition:

Cooperative / Not Oriented to time place & person / not,

Pulse - BP- Respiration- Temperature-

On Examination of ENT & head & neck

Inspection of Pinna:

Normal in shape, size, color, position, symmetry

Pre / Post / Infra auricular area: No Scar, Swelling, Sinus, Fistula, Sign of inflammation
On palpation:

No tenderness on pressure over tragus, cymba concha, on various movement of Pinna & over the
mastoid

On Examination of EAC :

Cartilaginous

Bony

Normal in shape & caliber

No wax, Discharge, Debris, Sign of inflammation, Polyp/ granulation/fistula seen

On Examination of TM RT / LT

1 Pars Tensa – is intact / perforated in PS /PI, AS/AI quadrant & is ………. % of Pars tensa, Shape ….Margin
of perforation is ……..

2 Color: Pearly grey (normal color) / White / Pinkish / Dull lusterless [ rest of the TM is …..in color]

3 Texture: Normal / Thick / Thin

4 land mark: -Short process of malleolus – prominent

-Anterior malleolar fold

-Posterior malleolar fold

-Handle of malleolus (foreshortened)

-Cone of light (AI/ Distorted/ Absent)

5 Tympanosclerotic patch / Epithelization / Retraction pocket / Granulation tissue / Air bubble /

incudostapedial joint (if present say where it is?)

6 On sigelization test: Mobile/ restricted / absent mobility (Pars tensa) & quadrant

7 thro’ perforation (Describe middle ear)

I can see ………..1 mucosa color [Pinkish –normal, Reddish / edematous if inflamed]

2 ET orifices, Promontory, RW, OW, and MEC filled with discharge.

8 Pars flaccida: is normal –Pinkish / if you say destructed then perforation is there & cholesteatoma
present say it where is it
Outer attic wall (scutum) how it is destructed due to cholesteatoma/not.

Fistula test: -ve / + ve

Facial nerve: all branches intact/ not.

History taking of nose case

Nasal obstruction-
o Sides,duration
o onset
o Partial or complete
o Progression ? if so partial to complete ? how long has the obstruction been complete?
o Associated
 with loss of sense of smell?
 Difficulty in breathing? Mouth breathing? Snoring while sleeping
o Facial pain or headache
o Aggravated by attacks of URTI, relieved with use of medication

Nasal discharge
o Sides, duration
o onset
o Nature, amount
o Blood tinged?
o Aggravting and relieving factors?
 h/o recurent sneezing, change in voice ( hyponasal voice), recurrent clearing of throat ( s/o PND)
 no h/o of diplopia, decreased vision, excessive lacrimation
 no h/o decreased hearing, rec ear ache, ear discharge
 no h/o rec sore throat, odynophagia, dysphagia, rec coughing, neck swellings
 no h/o chest pain, palpitation, abdominal pain ( ruling out systemic ilness)
Examination of nose and PNS

- Telecanthus – present/absent
- External osteocartilaginous framework –
 Normal
 Abnormal – dorsum deviated/ depressed dorsum/ saddle nose etc
 No swelling, scar mark, sinus, signs of inflammation
- Nasofacial groove, alar groove, nasolabial folds – normal/ obliterated

- Patency test – B /L equal, reduced on one side, absent etc

- Examination of vestibule

 caudal end of septum/ vestibular stenosis – midline/ deviated

 floor and lateral wall- normal /abnormal
 no crusting/fissuring/discharge/swelling/ signs of inflammation

- Anterior rhinoscopy
 Septum – midline/ deviated: overlying mucosa – normal ( pink) or pale or
congested
 Inferior turbinate and middle turbinate and their respective meatus and overlying
mucosa - normal, pale, congested
 If covered by mass, mention which part of these two turbinates are visible.
 If mass present
o Side – rt/ lt/ bilateral
o Single/ multiple
o color – pale, pink, reddish etc
o Shape- globular, grapelike
o covering the nasal cavity completely or partially or just meatus
o shrink on using decongestant
o on probing
 consistency – soft, firm , hard etc
 sensitive to touch
 bleeds on touch
 could pass the probe around which part of the mass – so the
probable site of origin is ……
 discharge if present – describe nature of discharge – mucoid/ mucopurulent/
purulent etc: mention amount
 If there is no discharge or mass seen – mention about the roof and floor of the
nasal cavity
 -Posterior rhinoscopy
o mention all the structures seen
o Posterior surface of uvula, soft palate
o Posterior end of the nasal septum
o B/L posterior end of

Superior turbinate

Middle turbinate

Inferior turbinate seen

o Eustachian tube opening normal
o B/L Choana - free
o No discharge /mass seen

-any discharge ( nature of discharge – mucoid/ mucopurulent/ purulent

etc: mention amount)
-any mass covering the choana

Paranasal sinuses

o the area over the paranasal sinuses – frontal, ethmoiidal, maxillary

sinuses is normal
o no swelling, scar marks, signs of inflammation
o on palpation – tenderness elicited over …../ no tenderness

Examination of eyes

- gross vision (diplopia,blurringof vision), epiphora, mobility of eyeball – normal

- infraorbital rim, proptosis (axial/non axial)

Examination of neck

Inspection

No swelling, scar marks, visible pulsation or engorged veins

Laryngeal framework is normal

Palpation

No local rise of temp or tenderness

 No lymphnodes or any other swelling palpable

Laryngeal crepitus – present

Trachea is central.

Auscultation
Examination of oral cavity

Trismus : Present /not

Vermilion border

Upper & lower Lips – normal/cracks fissuring/any abnormality present/not

Gingivolabial and gingivobuccal sulcus – normal

Buccal mucosa – normal

Gums and teeth – normal / any missing tooth or loosening of tooth if yes which tooth?

Retromolar trigone – normal

Anterior 2/3 of tongue – normal with normal mobility

Floor of mouth – normal

Hard palate – normal

Examination of oropharynx

Soft palate – normal with normal mobility

B/L Anterior and posterior tonsillar pillars – normal

B/L tonsils – normal / hypertrophied if so grade ?

Posterior 1/3 of the tongue Posterior pharyngeal wall – normal and gag reflex present / PND present?

On Indirect laryngoscopic examination

Base of the tongue ,

B/L valeculla,

Medial and lateral glosoepiglottic fold

Lingual & laryngeal surface of the epiglottis ,

B/L PE fold , AE fold, Arytenoids, FVC, Ventricles, TVC, Pyriform fossa normal /abnormal